INDIANAPOLIS — In 2013, Scott County Public Health Nurse Brittany Combs was thinking about leaving the day-to-day routine of smoking cessation classes and immunizations to take on a new challenge in the field of overseas missions work.

"Then we had an HIV outbreak so there was no time for that," Combs told about 60 healthcare workers this week at a conference looking at pre- and post-outbreak programs in the southern Indiana county and in the state.

Currently, the mostly rural Scott County has 231 HIV cases; in 2017, 12 new cases were reported. The Centers for Disease Control and Prevention estimated the county, based on the HIV population, could have expected 26 cases last year.

The outbreak was transmitted mostly through injection drug use. In Indiana, 8.6 percent of people testing positive for HIV are co‐infected with the Hepatitis C virus. Of those co-infected, 34 percent reported injection drug use, compared with the national average of 75 percent.

In the Scott County outbreak, 97.1 percent of the cases reported injection drug use.

The number of acute HCV cases in Indiana increased by 400 percent from 28 in 2010 to 140 in 2015 before the state declared a public health emergency.

In Scott County, more than a dozen programs have been implemented aimed at HIV prevention, mental health services, substance abuse treatment and, among others, a controversial syringe exchange program.

"Before the outbreak I had no idea how to reach that population of people. There was no way for me to get to them," Combs said. "But the needle exchange is the first line that a lot of these people get."

Since the outbreak, Indiana has numerous sites that screen for HIV and HPV including jails and prisons, Dr. Jennifer Walthall, Secretary of the Indiana Family and Social Service Administration, said.

She credited Scott County officials in part for Indiana gaining access to federal 21st Century Cures Act funds. Last year, the state received $10.9 million to combat opioid abuse and heroin use. The state recently learned that it will receive the same amount this year, Walthall said. An announcement on how those funds will be spent is expected Thursday.

Still, a stigma about HIV exists in the county.

For example, social health workers can teach Austin fourth- to sixth-graders about human development and seventh-graders about STD prevention with a focus on HIV. However, Scottsburg school officials limit programs on human sexuality education.

Tonja Eagan, CEO of Social Health Association of Indiana, said her association would prefer discussions of prevention as early as fourth grade. "But we're struggling with that."

In addition, the Indiana General Assembly recently passed, and Gov. Eric Holcomb signed into law, Senate Bill 65 which requires every school corporation to make human sexuality instruction material available for inspection by parents. Parents statewide must sign a statement saying they consent to the instruction.

Eagan said the process would be "challenging" for social health workers.

"We are constantly, constantly educating people especially with HIV because when you say the words HIV, your brain will shut down and all common sense goes out," Combs said.

Before 2015, there were no Hepatitis C or HIV care facilities in Scott County. The county jail offers recovery help and the county now has a recovery center solely for women.

For the first time in nine years, Scott County was no longer ranked the worst in health outcomes by the Robert Wood Johnson Foundation, moving from 92 to 91.

"We have a lot of work to do," Combs acknowledged, "but we've come really, really far in three years.

"The one thing that we have that we did not have before is a little bit of hope. If you can give people a little bit of hope, then you can change a lot for the future."